Case Conference-DepressionPREPARED BYWOO WING JUNELICIA CHIENG

Patient’s Particulars

Mr X29 year-old malay maleWorks as auditor in HSBC bankMarried for 3 years with no children

Chief Complaint

The patient was brought in to the emergency department by the father and presented with suicidal attempt by paracetamol overdosing of 10 tablets at one go on 18/11/2015.

What would you ask next?

History of Presenting Illness The wife requested for a divorce after his mother-in-law

passed away on the 1st October 2015 ( 2 weeks ago) The wife’s family blamed him for the death Previously, the mother-in-law had undergone renal transplant

in HKL in April 2015, but the patient was unable to pick her up upon discharge because his car was sent for service.

wife’s family were not happy with him Was informed that his mother-in-law was in critical condition

the day before her death, immediately booked tickets with his wife back to Miri. Able to see his mother-in-law before her death at 1.30pm, on 1/10/2015.

HOPI (continued) At the funeral, the father-in-law suddenly shouted in front of

the relatives and accusing him for causing his mother-in-law death

The wife changed the return tickets to the next Saturday(10th October) without notifying him, she insisted she will bear the extra charges on her own.

At the same time, the patient was tensed up with the urgent job in KL because his boss claimed that he would be reported to the Human resource department.

He ended up getting a warning letter from the HR department after he was back to KL on the Saturday.

What are the symptoms you would like to elicit from the

patient?

HOPI (continued) For the past 1 month,

felt depressed and disappointed vaped up to one bottle per day which he usually finished in 2

weeks had loss of interest in the things he used to do such as swimming,

bowling couldn’t concentrate and had poor attention at work leading to

poor performance of work, his boss started to pick on him frequently absent from work difficulty initiating sleep as he was preoccupied by his wife

Sleeps at 11pm, and frequently wakes up in the middle of night at 1am, 3am and 4am,felt weak and experienced headache in the morning the other day

loss of appetite waist circumference reduced from 46 inch to 38 inch, and

Tshirt size from XXXL to XL once suicidal ideation by jumping into the swimming pool no auditory hallucination no manic or hypomanic symptoms

Past psychiatry history

He was seen in the psychiatry clinic in 2011 for low mood after problems with his girlfriend who is now his wife.

He wasn’t given any medication that time.

Past medical history

patient had asthma, and last attack was at the age of 17

mid hypertensive and not on any anti-hypertensive medication

had done extracorporeal shock wave lithotripsy (ESWL) for removal of kidney stone in 2014

urinary tract infection within 2015

Family History Both the parents are in 70s Eldest brother is 47,married with 4

children, works as engineer Second brother is 41 with intellectual

disability with psychosis Third brother is 36, works as engineer

and married with 4 children Sister is 31, works as doctor in Miri,

married with 2 children Relationship with family members is

good. Otherwise, no other psychiatry

illness,suicide in the family

 

 

     

Personal History Perinatal history was unable to be elicited childhood obesity and asthma Average student, science stream active in sport such as taekwando, bowling and

swimming further his study in Degree of Accounting at UNITEN,

and subsequently took ACCA in gold coast, Australia many close friends from the school No major disciplinary problems

worked in hotel SPA for 2 months in Bahau after back from Australia, his mum asked him to back to KL.

So, started working in AIG for 3 months HSBC bank since 2008 until now

Love marriage, married for 3 years with no children Wife is studying quantity surveying Frequently argue over small matters wife had asked for divorce due to marital discord over

the past 1 month Financial constraint, earn 3k a month with car loan,

house loan, and credit card debts No criminal record noted

took alcohol (Heineken) on weekly basis when he was in UNITEN, average 3 big bottles each time

Stopped after back to Malaysia

denied cigarette smoking However, he vaped every day, and used to finish one

bottle in 2 weeks, but has been finishing a bottle each day

No substance or illicit drug use

Premorbid Personality

hot-tempered person sometimes likes to be alone likes to go on vacation vapes or heads to gym when he is stressful

Mental State Examination General appearance

well-groomed malay male dressed in hospital attire Unshaven, messy hair Conscious and forthcoming maintained good rapport and eye contact but at times, he

distracted by surrounding people no abnormal movement noted

Speech and thought Speech is coherent and relevant with normal amount, tone

and rate Has suicidal thought (jumping into pool or fire)

Mood and Affect Mood is euthymic and was congruent to the affect

Perception no hallucination (but he reports hearing voices

asking to kill himself when he felt depressed in the ward)

No illusion, flashbacks, depersonalization, and derealization

Cognitive function Orientation

disorientated to time, place and person Memory

remote and recent memory were intact Able to recall 3 out of 5 words in the 5 minute work

test Information and Vocabulary

appropriate to his age, education level and sociocultural background

Abstraction able to tell the similarities between apple and orange

in abstract manner Attention and concentration

couldn’t perform serial 7 test but he managed to count digit span and spell “world” backward

Judgement impaired as he would jump into fire when he saw a

building caught on a fire Insight

Good insight

Provisional diagnosis Severe Major depressive disorder with

psychosis

Differential Diagnosis

Prodrome of schizophrenia Schizoaffective disorder Bipolar disorder in depressive phase

Investigation

Full blood count Liver function test Renal function test Thyroid function test ECG

Psychiatric Formulation

AetiologyBIO PSYCHO SOCIAL

Predisposing factors

• Dependent personality

• Pampered child• Hot-tempered

• Financial constraint• Frequent argument with

wife• Disliked by the wife’s

family

Precipitating factors

• Divorcement • Difficulties in work

Perpetuating/maintaining factors

• Unresolved marriage problem

ManagementBIO PSYCHO SOCIAL

Acute

• Detoxification• Anti psychotics for

auditory hallucination • Anti depressants

(Escitalopram)• Admitting patient to

ward to monitor

• Allow patient to vent or speak out his problems

• Family support

Long Term

• Anti depressants• Electroconvulsive

therapy (if treatment resistant, high suicidal risk)

• Cognitive behavioural therapy

• Psychodynamic therapy• Supportive

psychotherapy

• Marriage counsellor• Social support from

family members

THANK YOU!

ANY QUESTIONS?